The Next 4 Years: Battlegrounds in Science, Medicine and Environment

As is usually the case following an election, promises of bipartisanship bloom ubiquitous. Finally, say politicians and partisans, we'll reach across the aisle, find common ground, negotiate constructive compromise and generally get the job done.

Will those intentions hold true? It's impossible to know. But the next four years will give America to a chance to shape, for better or worse, a host of vitally important scientific, medical and environmental issues.

Here is some of what we'll be arguing over -- and hopefully figuring out -- in years to come.

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Climate Change

After the collapse of federal legislation in 2010, climate change replaced social security as the third rail of American politics. But following the epic midwestern floods of 2008 and 2010, this year's drought and finally Hurricane Sandy, the winds appear to be changing.

"You have stakeholders on both sides of the aisle talking about this stuff," said Eric Pooley, senior vice president of the Environmental Defense Fund. "It's not just, 'Let's go back to the last climate bill and begin conversation there.' It's, 'Let's start again.'"

A cap-and-trade system for carbon pollution is unlikely, but other approaches are possible, from adapting infrastructure and improving post-disaster resilience to revenue-neutral carbon taxes and reduced fossil fuel subsidies. "We want a broad, inclusive debate here. We want people competing for the best ideas," said Pooley. "There's never been a landmark environmental bill passed in this country that didn't have overwhelming bipartisan support.

Genome Dilemmas

Though it's taken longer than expected, the promise of genome-based insights in medical care is starting to be fulfilled. The price of genome sequencing continues to fall; more importantly, genetic information, especially in regard to drug response, is becoming actionable.

"There are many institutions gearing up to do this as part of their routine clinical care," said Daniel Rader, director of the University of Pennsylvania's Clinical and Translational Research Center. "There are huge challenges, not least of which is the tremendous amount of data that's generated. Sifting through that data to find things truly relevant to an individual is a huge informatics challenge -- not just the hardware for storing data, but the human capital required to sift through it, make sense of it, and translate it for appropriate use."

There's a shortage of genetic counselors in the United States, says Rader. There's also a need for more consumer protection: Though discrimination based on genetic information is illegal in health insurance, genetic discrimination is still possible elsewhere. "Someone who has their genome sequenced may be at risk of being turned down for life insurance," Rader said. "There are a lot of implications for this revolution, and it's coming."

The Future of Farming

Though innocuously named, the farm bill guides food production and consumption in the United States. The latest version, presently stalled in Congress, would account for nearly $1 trillion in spending over the next 10 years. Negotiations on the bill will soon resume. As the problems of industrialized agriculture -- pollution, accelerated disease evolution, over-reliance on chemicals and fertilizers, vulnerability to natural disaster -- become inescapable, the farm bill offers a chance to solve those problems.

One major point of contention will likely be corn-based ethanol fuel, originally envisioned as a clean energy source but now recognized as being fossil fuel-intensive to produce and having destabilizing effects on food prices. "I would start with ethanol," said Audubon Society president David Yarnold of farm bill reform. "Its value in the fight against carbon pollution is negligible, and I think we all know that."

Alzheimer's Drugs for Everyone

More than 5 million Americans -- including an estimated 1 in 8 people over 65 years old -- suffer from Alzheimer's disease, a neurological affliction that is dreadful, costly, difficult to detect and impossible to cure. That could soon change for the better, said bioethicist Art Caplan of New York University, but the fallout will be profoundly contentious.

"We're going to see advances in the early detection of Alzheimer's. That's going to cause a huge amount of controversy and anxiety in terms of making testing available and pressures to find treatments," Caplan said. One of the most promising treatments is called intravenous immunoglobulin, or IVIg, which is now in phase 3 clinical trials. If it or some other Alzheimer's drug works, the demand will be immense, and it won't be easy to satisfy.

"There are things that look promising with drugs, and it's going to be a political challenge to make them," Caplan said. "IVIg is a very difficult product to make. It will take a long time to get plants up and running and through approval. We have a hard time making some simple drugs now in factories, and this stuff is an order of magnitude more complex." There may also be public pressure to make the drug affordable, setting up a collision between industry and government.

End-of-Life Decisions

Though a ballot proposal to legalize doctor-assisted suicide was narrowly defeated in Massachusetts, the issue is not going away. America is aging rapidly, and many terminally ill people are choosing to forgo expensive, marginally effective, spare-no-expense treatment in favor of palliative care that emphasizes comfort and dignity. It's only a small step from asking what constitutes a good end of life to what makes a good death.

Weighing the Evidence

With Obamacare and widespread awareness of unsustainable U.S. health spending came a renewed focus on preventive medicine and what's known as evidence-based care: Treatment guidelines and insurance coverage based on systematic reviews of clinical results, eschewing tests or treatments that are expensive but offer limited clinical benefit.

If this sounds simple in theory, the reality is far messier. Physicians and scientists often disagree over how evidence should be interpreted, and the outcome is ultimately a cost-benefit analysis in which some suffering is simply too costly to avoid. Bitter fights over prostate cancer screening and breast cancer exams foreshadow battles to come.

Next-Gen GM

Debate over genetically modified crops tends to focus on shaky scientific concerns about their dietary safety, or fears that excessive regulation will stop the development of extra-nutritious, extra-hardy crops. These questions are secondary to the commercial reality of GM crops, the most popular of which are designed to withstand high doses of the herbicide Roundup.

More than 90 percent of U.S. soybeans and 70 percent of corn and cotton is Roundup-resistant, an over-reliance that accelerated the evolution of Roundup-resistant weeds. Most of the genetically modified crops now in commercial development, and scheduled for federal review in the next several years, represent a chemical answer to this quandary: They're designed to withstand heavy doses of multiple herbicides, including highly toxic chemicals that Roundup was originally supposed to replace.

They suggest a future in which agriculture is far more chemically intensive than it already is, leading some scientists to say that farming in the U.S. is at a crossroads.